Executive Case Manager (Remote)

Executive Case Manager

Valeris is a fully integrated life sciences commercialization partner that provides comprehensive solutions that span the entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris revolutionizes the path from life sciences innovation to real-life impact to build a world in which every patient gets the care they need. Valeris works on behalf of life sciences companies to improve the patient experience so that patients can access and adhere to critical medications. Backed by proven industry expertise, a deep commitment to patient care, the latest technology, and exceptionally talented team members, Valeris provides the data and strategic insights, patient support services and healthcare provider engagement tools to help life sciences companies successfully commercialize new products. Valeris provides commercialization solutions to more than 500 life sciences customers and has provided access and affordability support to millions of patients. The company is headquartered in Morrisville, North Carolina and Jeffersonville, Indiana.

This is a remote role. Candidates must reside in the state of North Carolina. When you join the team as an Executive Case Manager, you'll have the opportunity to make a difference in the lives of our patients each day as they look to you as part of their dedicated support team for helping them navigate the tricky process of getting access to their complex medication. You'll compassionately deliver an exceptional experience to many patients per day always remembering that every prescription or document belongs to a real person who is looking for thorough and efficient management of their records. You'll adjust your approach to their needs by communicating clearly, focusing on the accuracy of the details of their medical records, your mastery of the program requirements, and ensuring their prescriptions or cases are handled in a timely manner. An Executive Case Manager has the ability to translate knowledge into patient friendly language and education. A typical day in this role will include ownership of your patient journey from initiation to closure by using your critical thinking skills and your knowledge of the program and industry rules and standards. This includes completing benefit investigations, tracking prior authorizations / denial appeals, and assisting patients or other callers/stakeholders through resolution (via email, inbound/outbound calls and using our patented technology, Lynk). This role requires a strong understanding of pharmacy and medical billing and coding, excellent communication skills, and the ability to navigate complex reimbursement processes. The Executive Case Manager provides expertise on insurance coverage and common access and reimbursement challenges affecting patients, healthcare providers and clients. The Executive Case Manager responsibilities include education on the access and reimbursement support tools available from PharmaCord and participating program, advising HCPs and/or patients and caregivers on the benefits and program eligibility for a specific patient, and educating HCP offices on Payor processes and procedures.

Key Responsibilities:

• Relationship Management
• Manages all relationships in a manner that adheres to all relevant laws, regulations, program-specific operating procedures and industry standards related to access and affordability, including HIPAA and insurance guidelines.
• Managed through call/contact center structure, this role supports inbound and outbound calls to patients, caregivers, specialty pharmacies and healthcare professionals.
• Performs post Benefits Investigation calls to patients and/or physicians explaining coverage options and next steps in the access journey.
• Manages all client inquiries as appropriate, such as case specific statuses.
• Manages HCP inquiries, as applicable, pursuant to business rules.
• All communications with the client's field teams will remain compliant and adhere to ways of working protocols outlined between PharmaCord and the client teams.
• Inbound Call Management
• Manages inbound calls as directed by the program-approved FAQs
• Triage patients to internal or external resources as appropriate.
• Personalized Case Management
• Provides personalized case management to patients and HCPs including outbound communication to HCPs, specialty pharmacies and patients to communicate benefit coverage and/or appropriately help drive next steps in obtaining coverage and/or access to prescribed medicine. All communications for case management will follow the guidelines set forth for the program and only provide information publicly available and/or outlined in the patient insert.
• Leverages electronic tools to identify benefits and payer coverage; completes manual benefit investigation as needed.
• Identifies and communicates patient's plan benefit coverage including the need for prior authorization, appeal, tier exception, and/or formulary exclusions.
• Serves as a subject matter expert to internal team as required and appropriate.
• Uses electronic resources to obtain benefit coverage outcome and if needed, outbound call to payers and HCPs to follow up on proper submission and/or outcome.
• Coordinates nurse teach with nurse educators, as applicable to program.
• Supports adherence services as applicable to program.
• Identifies peer support resources for patients.
• Proactively communicates needs for reverification of prior authorization or re-enrollment.
• Identifies and reports adverse events, product complaints, special situation reports and/or medical inquiries received in accordance with program operating procedures and the Business Rules.
• Documents all activities within the PharmaCord Lynk system, maintaining detailed records of reimbursement activities, including claims status, payments, and appeals.
• Generate reports and analysis as needed to identify trends and opportunities for improvement.in accordance with business requirements.
• Utilize Valeris' values as the driving force behind the team's success
• On time adherence to training deadlines for all corporate policies and procedures
• Ensure all SOPs are followed with consistency
• Perform additional tasks or projects as assigned

Qualifications:

• Completion of Bachelor's degree (or higher) required
• A degree in healthcare administration, social science or similar related fields is strongly preferred.
• Minimum two years of experience in healthcare access delivery or management is strongly preferred.
• 5-10 years of experience in insurance reimbursement, patient access, direct patient care, and/or patient education experience will be considered in lieu of degree.
• Will consider other certifications and five or more consecutive years of experience in relevant field. Certification examples include PACS (Prior Authorization Certified Specialist), CHES (Certified Health Education Specialist) or CCM in healthcare or social science (Certified Case Manager).
• Strong understanding of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance processes.
• Demonstrated examples of executing within guardrails recognizing urgency and consistently delivering patient centric results.
• Excellent attention to detail and organizational skills.
• Ability to prioritize tasks and work efficiently in a fast-paced environment.
• Effective written and verbal communication and interpersonal skills, with the ability to interact professionally with diverse stakeholders.
• Demonstrates the ability to think critically and issue resolution.
• Knowledge of healthcare compliance regulations, including HIPAA and Medicare/Medicaid guidelines.
• Bi-lingual skills are a plus.
• Remote work eligibility is subject to all work from home criteria met and based on business need

Physical Demands & Work Environment:

• While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to sit for long periods of time, use hands to type, handle or feel; and reach with hands and arms. Prefer candidates who can type at least 35 words per minute with 97% accuracy.
• Although very minimal, flexibility to travel as needed is preferred.
• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, etc.

Why Work for Valeris? We're committed to supporting the well-being and success of our team members. As part of our organization, full-time employees can expect:

• Medical, dental, and vision plans, including HSA- and FSA-eligible options, with Valeris contributing toward premium costs
• Additional health support, including telehealth and Employee Assistance Program (EAP) services
• Company match on Health Savings Account contributions
• Free Basic Life and AD&D coverage equal to your annual earnings, with a minimum of $50,000 and a maximum of $300,000
• Company-paid Short-Term Disability coverage, with the option to purchase Long-Term Disability
• 401(k) Retirement Savings Plan with 100% match on the first 5% you contribute, with immediate vesting
• Paid Time Off (PTO) and Sick Leave to support work-life balance